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Cluster of measles cases confirmed among adopted children from China
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Two cases of laboratory-confirmed measles were identified in recently adopted children from an orphanage in Henan Province, China in July 2013, according to this week’s MMWR.
The two cases occurred in a boy (case A) and a girl (case B), aged 2 years with cerebral palsy. Both became ill before traveling to the United States and were symptomatic before travel. Shortly after arrival in the United States, both children were hospitalized. Neither of the children had documented measles vaccination, but their adoptive parents had affidavits for exemption of recommended vaccines until arrival in the United States.
No secondary cases of measles were found during an investigation of 83 crew members and passengers traveling with the infected children. Contact investigations found that six people were susceptible to measles and three received post-exposure immunoglobulin.
Two additional cases of measles were later identified, one in another child (case C) adopted from China at the same time as the original cases and another in the adoptive mother (case D) of one of the original cases. Investigations of an additional 19 people in that family yielded no additional cases.
Case C was asymptomatic upon arriving in the United States but developed a fever and rash and tested positive for measles on July 16. Case D tested positive for measles on July 19 following the appearance of a rash.
“Two of the ill children reported in this cluster were symptomatic and contagious en route to the United States, potentially exposing their families, many travelers, and hospital patients and staff members to measles,” the researchers wrote. “Had they been identified as infectious with measles before travel and prevented from boarding, subsequent contact investigations by health officials and the substantial costs associated with control of the outbreak could have been avoided. More importantly, routine vaccination according to recommended schedules likely would have averted this outbreak. Public health and adoption agencies should continue to promote appropriate vaccinations for adoptees and their adoptive families.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Michael J. Chusid, MD
The recent report of four cases of measles associated with the international adoption of non-measles immunized children from China underscores the caution adoptive parents and caregivers must take when dealing with children who are ill upon departure from a foreign country or who become ill on the trip home or within the first 2 or 3 weeks after arrival in the United States.
Internationally adopted children with a febrile rash illness must be considered potentially contagious for measles, particularly coming from parts of the world, like China, where measles is contagious, especially if they have not be immunized. Such children are a potential huge risk to fellow travelers in the close confines of an airplane cabin. After arrival they also put adoptive parents, families, and other caregivers in the home at risk of infection.
Primary care providers need to be aware that febrile, newly adopted children may be manifesting symptoms of highly contagious infectious diseases not often seen in the United States, such as mumps, hepatitis A, tuberculosis, measles, or newly emerging respiratory agents like SARS and MERS. When seeing a sick adoptee for the first time, rather than having that child sit among other patients in the waiting room, it would be appropriate to place the child in an examining room with a closed door and taking appropriate protective steps (potentially gloves, gowns, masks, depending on symptomatology) before assessing the child. In the case of a non-immune adoptee with a fever/rash illness from a country known to active endemic measles, it may make sense to have the child evaluated at a facility capable of placing the child in a negative pressure environment as he or she is assessed. It is incumbent to warn the receiving facility about the possibility of measles or other contagious disease in such a child, before the child arrives, so that the facility can be prepared to isolate the child properly.
Finally, it seems inappropriate from medical and ethical points of view to allow incompletely immunized, febrile children to board public conveyances and expose potentially vulnerable individuals to potentially serious, even fatal contagious infections. While parents, including adoptive parents, currently have the right to delay or even refuse immunizations for their children, they do not have the right to expose others to serious infection. Clearly, this is an issue that will need to be addressed by international public health authorities.
Perspective
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Mary Allen Staat, MD, MPH
While international adoptions have declined in recent years, many children from abroad are still arriving to the United States to join their new families. China is the leading country for international adoptions in the United States and unlike in past years, nearly all children from China have medical and/or developmental special needs. Even though routine immunizations are not contraindicated for the vast majority of these special need conditions, many of these children have not received age-appropriate immunizations prior to their arrival to the United States due to this special need. As health care providers caring for these families it is important that we prepare our families, those traveling and those at home, to be current with their immunizations prior to the arrival of these children.
For measles prevention, those born on or after 1957, should have two doses of a measles-containing vaccine. Other vaccines that should be current include diphtheria-tetanus toxoids-acellular pertussis/tetanus-diphtheria-acellular pertussis, hepatitis A, hepatitis B and varicella vaccines. While in country, parents should be instructed to seek medical advice if their child is ill, especially with an illness with fever and a rash, to determine the cause of the child’s illness and when their child should travel. Health care providers should also see all internationally adopted children within the first 2 weeks of arrival for a thorough medical evaluation and to make an immunization plan to assure they promptly receive the recommended immunizations that are needed. With these measures, future outbreaks of vaccine-preventable diseases can be prevented.
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